Health inspection·October 13, 2023

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to readmit one out of two sampled residents (Resident 1) from the General Acute Care Hospital 1 (GACH1) after the resident was cleared by GACH 1 to return to the facility on 9/14/2022. This deficient practice resulted in denial of Resident 1 ' s right to return to the facility where she lived. Findings: During a review of the facility census (daily official count and list of residents admitted to the facility) dated 10/13/2023, the census indicated 40 in house residents and 3 bed holds (if a resident is transferred out, the facility reserves the resident ' s bed for seven days) for residents not in the facility. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including cerebral palsy (a condition that affects muscle tone, movement, and coordination that limit activity), dysphagia (difficulty swallowing), muscle weakness, diabetes mellitus (high blood sugar) and urinary tract infection. During a review of Resident 1's History and Physical (H&P), dated 7/29/2023, the H&P indicated Resident 1 does not have capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 7/13/2023, the MDS indicated Resident 1's cognition (the ability to think, reason, and understand) was severely impaired. The MDS indicated Resident 1 was totaly dependant on two-person assistance for bed mobility, toileting, eating, dressing, and personal hygiene. During a review of Resident 1 ' s order summary dated 9/8/2023, the order summary note indicated Resident 1 had a seven-day bed hold, in place if Resident 1 were to be temporarily transferred out, and readmitted . During a review of Resident 1 ' s Physician ' s orders dated 9/30/2023, the order indicated to transfer Resident 1 to a GACH due to desaturation (abnormally low blood oxygen concentration). During a review of Resident 1 ' s general acute care hospital (GACH) ombudsman (public advocate) (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056104 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)